1. The document summarizes information from a presentation on rotator cuff injuries, including their etiology, classification, and surgical treatment options. 2. It describes how rotator cuff tears are classified based on their size and provides examples of repair techniques used for different types and shapes of tears. 3. The presentation discusses ongoing research studying rotator cuff injuries, including investigating genetic and epigenetic factors associated with risk and analyzing gene expression changes in injured tendons.

1. Chefe do Departamento e Professor Titular: Prof. Dr. Moisés Cohen
Professores Titulares: Prof. Dr. Walter Manna Albertoni
Prof. Dr. Flávio Faloppa
Prof. Dr. Akira Ishida

2. Federal University of São Paulo – Brazil
Chief Moisés Cohen, M.D.
Benno Ejnisman, M.D

3. • Most common cause of
debilitating shoulder pain in
adults
• Etiology – multifatorial
• Factors
Intrinsic – tendon
Extrinsic
Malcarney Sports Med 2003

4. •
De Orio and Cofield
Bayne and Bateman
•
Geber
Harryman
•
Ellman
Burkhart
Wolfgang

5.  Full-thickness tears
 Classify the SIZE of the tear by the
widest diameter:
______Small (<1 cm)
______Medium (1-3 cm)
______Large (3-5 cm)
______Massive (>5 cm)

6. Complete cuff tears: Bateman
Classification
 Grade 1 - Tear < 1cm after debridement
 Grade 2 - Tear 1-3 cm after debridement
 Grade 3 - < 5 cm
 Grade 4 - Global tear, no cuff left

7. Ellman H, Gartsman G, Open repair of full thickness RCT. Pg 181-202,
Philadelphia, 1993

8. • Patte
• Snyder

9. : Anterior lesions-
Subscap tendon, rotator
interval and LHB tendon
: Central superior
lesions- supraspinatus tendon
: Posterior lesions-
infraspinatus and teres minor
lesions
Habermeyer, JBJS (A) 2006

10. , crescent-shaped tears are repaired
end to bone and have a good to excellent
prognosis.
, longitudinal (L- or U-shaped) tears are
repaired side to side with margin convergence
and have a good to excellent prognosis.

11. massive contracted tears
have coronal and sagittal dimensions greater
than 2 2 cm on preoperative magnetic
resonance imaging; are repaired with interval
slides or partial repair; and have a fair to good
prognosis.
rotator cuff arthropathy tears have
end-stage degenerative changes of the
glenohumeral joint and have articulation of the
humeral head with the undersurface of the
acromion; are irreparable; and require
arthroplasty if surgery is considered.

13. • Total rupture
Double row repair
Health tissue

14. 2005
HR, masculine – 83 years
2004
• Total rupture Bad
quality tissue

16. MULTIFATORIAL
ETIOLOGY
MULTIDISCIPLINARY
TREATMENT

18. POSTERIOR
A
N
T
E
R
I
O
R

20. MORE ANTERIOR MORE POSTERIOR

21. • Ageing
• Hipovascularity
• Life style
• Sports modality

22. • 16 patients submitted to arthroscopic repair
• 12 female / 4 male
• Age: 39-73 years (average 54 years old)
• Traumatic: 18.5%
• Time between pain and diagnosis: 3-48 months
(average 16.5)

23. • Total tendon rupture: 16 cases
• Rotator cuff tendons:
– Supraespinnatus: 100%
– 2 tendons involved: 31.25%
– 3 tendons involved: 18.75%
• Size of lesion: 1-4cm (average 2.14cm)
• Shape of acromium: Type II 81.25%

25. • Lateral border ................... Few or none
81.15%
• Medial border and bursa ..... Moderate or
A Abundant 50%
• Lateral Border .................. None 93.75%
• Medial Border .................. None 50%
• Bursa .................................... Present 81.25%

26. Lateral Border Medial Border

27. Subacromial Bursa

30. 1. Compare the allele and genotype
polymorphisms in patients with rotator cuff
injury
1. Comparing mRNA expression in samples of
the rotator cuff tendon with and without
injury.
2. Compare the pattern and frequency of DNA
methylation of selected genes in samples of
rotator cuff tendon with and without injury.

31. 4. Correlate mRNA expression, DNA
methylation, miRNA and DNA polymorphisms.
5. To investigate the association of
polymorphisms, mRNA expression and miRNA,
and frequency and pattern of DNA methylation
with clinical variables, such as gender, age,
ancestry, time of onset of disease, injury, total
or partial rotator cuff, orthopedic and
variables comobirdades clinics.

32. PERIPHERICAL
BLOOD
SUPRAESPINATUS
BIOPSY

33. 1. Identification of genetic polymorphisms
associated with risk of rotator cuff
2. Identification of genes with altered expression
involved in the rupture of the tendon of the rotator
cuff. The study of these changes may help in
understanding the reasons why solid surgical repair
of this tendon may fail.
3. Elucidation of epigenetic mechanisms such as
DNA methylation in gene regulation related to
rotator cuff injury. The control mechanisms of gene
expression is tissue specific and / or specific
pathology.

34. FEDERAL UNIVERSITY OF SÃO PAULO
Pochini A & Ejnisman B. e cols., Journal of Orthopaedic Research, 2011

35. Treadmill
RAT WINSTAR 350gPochini A & Ejnisman B. e cols., Journal of Orthopaedic Research, 2011

37. HISTOLOGICAL AND IMMUNOHISTOCHEMICAL
EVALUATION OF ROTATOR CUFF OVERUSE MODEL
IN WINSTAR RATS

40. p=0,07

42. S100 – 200X
S100 – 400X

43. CONTROL RUNNING
8 WEEKS p=0,06

44. Growth factors
Gene therapy
Biomechanics
Tissue engineering
Prevention
Surgical treatment
Rehabilitation programs

45. MESENQUIMAL CELLS IN PROXIMAL
HUMERUS IN PATIENTS WITH
COMPLETE ROTATOR CUFF TEARS
MORE THAN 50 YEARS OLD

46. • ASPIRATION ILIAC CRIST +++
• ILIAC CRIST GRAFT ++++
• TIBIAL GRAFT +
• ASPIRATION FROM PROXIMAL
HUMERUS ++

49. METODOLOGIA
Red cells
Ficoll
Mononuclear
Mesenquimal
cells

51. A
D
B
C
A: Células mesenquimais em cultura(40X); B: Células mesenquimais diferenciadas em condrócitos
evidencias Azul de Touluidina (cora deposição de colageno na matriz extra celular)(60X); C: Células
mesenquimais diferenciadas em adipócitos evidenciadas por Oil Red (marca a presença de lipídeos
dentro dos vacúolos) (100X); D Células mesenquimais diferenciadas em osteócitos evidenciadas por
Alizarina Red ( marca a deposição de calcio na matriz extra celular) (100X).

52.  AVOID OVERRUSE IN PREDISPOSAL
POPULATION
 UNDERSTAND ANATOMY
 CLASSIFY THE LESION
 AVOID SMOKE
 PREVENTION EXERCISE FOR ROTATOR
CUFF – IMPROVE PROPRIOCEPTION

53.  DEBRIDE EDGE OF THE LESION
 GENTLE MANIPULATTION OF THE BURSA
 PREPARE SUBCHONDRA BONE
 AVOID MUSCLE ATROPHY – NEW
TECHNOLOGIES

54. Benno Ejnisman
THANK YOU
VERY MUCH